Inspection on 07/09/05 for Maple Lodge Nursing Home

This inspection was carried out on 7th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Maple Lodge Nursing Home 04/12/08

Maple Lodge Nursing Home 18/12/06

Maple Lodge Nursing Home 22/02/06

Maple Lodge Nursing Home 24/02/05

Maple Lodge Nursing Home 09/09/04

Maple Lodge Nursing Home 23/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Maple Lodge Nursing Home Witherwack Sunderland SR5 5SF Lead Inspector Sam Doku Unannounced 7 September 2005 08:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Maple Lodge Nursing Home Address Woolwich Road Witherwack Sunderland SR5 5SF 0191 549 3672 0191 549 3687 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tamaris Healthcare (England) Limited Care home with nursing 54 Category(ies) of DE Dementia (30) registration, with number DE(E) Dementia - over 65 (30) of places OP Old age (24) MD(E) Mental Disorder -over 65 (15) MD Mental Disorder (15) Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NO Date of last inspection 24 February 2005 Brief Description of the Service: Maple Lodge is a two storey care home which was purpose built in 1995 and offers accommodation to a maximum of 54 older people. The home provides both personal and nursing care to those living there, some of whom may have dementia, mental health needs or general nursing care needs. The property is located in a residential area of Witherwack and is within walking distance of a small range of local amenities, including shops, a post office, and a pub and bus station to the city centre of Sunderland. Local churches are accessible by car or public transport. A mini-bus is available to the home for use by service users but this must be pre-booked. Accommodation is provided on two floors, each with self-contained facilities including lounges, dining areas, WC’s and bathrooms. All bedrooms are single rooms, of good size and are provided with en-suite WC facilities. Entry to the home is accessible with lift access to the first floor. Externally, generous car parking space is provided to the front of the building, and extensive grounds surround the home. This area is enclosed with fencing for security but would benefit from landscaping. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection involved one inspector and was carried out at 08:00am in the morning to observe the early morning practices in the home, and the arrangements for getting service users up and out of bed. Before the date of the inspection, a pre-inspection questionnaire was sent to the manager to complete and return to the inspector. Surveys were sent to service users and relatives for their comments on the service that they receive. The comments received were positive about the service and indicated a general satisfaction from both service users and relatives. These comments had been incorporated into the body of the inspection report. Observations of staff practices and procedures, examination of documents and records and discussions with staff and management, also contributed to the inspection findings. The atmosphere and environment within the Home was friendly, relaxed and comfortable throughout the time of the inspection. A number of service users and a visiting relative were spoken with. All were very complimentary about the Home and the staff. Service users appeared cared for and comfortable with the staff. Staff were professional in their manner and care practices. What the service does well: Service users spoke very highly about the opportunities available to them for regular bus trips to local places of interest. Some service users spoke about the recent appointment of an activities coordinator. Those spoken with stated that they find the social and recreational activities organised by her interesting and that she is enthusiastic about her work. Staff have nice attitude and conduct themselves in a professional manner. Staff interaction with service users was friendly but professional and service users commented positively on the staff approach to them. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The home has large grounds round it but the place is overgrown with grass with grass and parts of the ground are inaccessible to the service users. The manager stated that the company is in the process of contracting this to an agency to address this. At the time of the inspection it was noted that some if the dining tables and chairs were damaged and need to be repaired. However, the manager confirmed that the home is expecting new delivery of chairs and tables that week. A suitable assisted shower must be provided as the current one is inadequate and seriously compromises the safety of the service user and the staff engaged in such activity. It also infringes on the dignity of the service users as the door cannot be fully closed when a mobile hoist is being used to assist in the shower room. The heights of mirrors, toilet roll holders and soap dispensers in accessible WC’s need to be relocated to meet the needs of disabled service users. In the last inspection report, a requirement was made for the home to consult with the service users or the representatives regarding the management of the finances. This should be addressed to ensure that service users are aware that monies left in the care of the home and saved on their behalf do not accrue interest on the amounts. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5. Assessments are completed prior to admission to ensure that the needs of potential service users can be met. Pre-admission information is available to prospective service users and their relatives as well as the opportunity to visit the home to enable them to make informed choice about whether or not Maple Lodge is suitable to meet their needs. EVIDENCE: Four service users files were examined and these contained assessments by social workers/nurse assessor and by the senior staff of the home. The manager explained that it is the policy of the home that social workers or a nurse assessor from the PCT provided a full assessment of a prospective service user to the home before admission is arranged. In an emergency admission it is expected that such assessments would be provided by the social worker or a nurse assessor within 48 hours of admission. The manager confirmed that it is the policy that a senior staff member would visit prospective service users in their own homes and carry out an assessment of Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 10 their needs before admission. This is to ensure that the care needs of the service user are properly assessed and to assure the user that their needs can be met. Some service users who were spoken with said they were visited in their own home or place of residence by a social worker and a representative of the service. They indicated that this gave them the opportunity to ask appropriate questions about the service. Two service users indicated that they had the opportunity to visit the home and view her room before coming to live in the home. One visiting relatives also stated that he viewed the home for the relatives before making the final decision for his mother to move to Maple Lodge. This process ensures that service users and their relatives are confident about the facilities available to promote their care. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10. The individual care plans set out the health, social and personal care needs of each service user and plans are formulated to meet those care needs. This has ensures that the care needs of the individuals are met. However, more information is required in identifying the religious and recreational needs of the service users. The service users are treated with respect and dignity by the staff. EVIDENCE: The care plans that were examined were found to provide details of service users care needs and how those needs are to be met by the staff. There was evidence in the care plans that some service users or their relatives have been encouraged to be involved in the formulation of their care plans. Risk assessments have also been carried out for those service users for whom it is thought necessary. These include falls, nutrition, moving and handling and pressure area and smoking risk assessments. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 12 The files that were examined provided evidence of service users health care needs being met. The records contained evidence of visits by GPs, Chiropodists, Opticians, and also visits by or to other specialist healthcare personnel such as hospital consultants and psychiatrists. The records also contained evidence of regular checks on service users’ weights and nutritional assessments being carried out to ensure that all the service users receive adequate and nutritious diet. All the service users are registered with a GP service. The service users who were spoken with all confirmed that their healthcare needs are adequately met and that the arrangements for their care are good. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15. Service users are encouraged and supported to lead active lifestyles based on their preferences and choices although for some people the lack of information about recreation and religion may limit the opportunity to exercise real choice. Service users are offered and receive a varied, wholesome, nutritious diet. This can contribute to their general health and wellbeing. EVIDENCE: In examining service users’ files it was evident that the care needs of the service users have been clearly identified and methods of addressing those needs have been stated. However, in some of the files, the sections on social care contained limited information on the recreational and religious needs. The manager stated that these areas are being updated with the view to providing better information about service users’ social, recreational and religious needs. Despite the limited information in the service users files in this respect, those spoken with indicated that they feel that their social and recreational care needs are met by the staff. Some cited the role of the activities coordinator and how they enjoy and the bus trips that are organised for them on regular basis. They also made reference to a recent professional singer performing for them in the home. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 14 A relatives who was spoken with stated that he is able to visit at anytime convenient to him and his family and was very appreciative of this level of flexibility. Service users confirmed that the daily routines are organised flexibly to take account of individual likes and dislikes. Two service users cited meal times and bed times as examples of such flexibility. The service users stated that although there are set times for meals, they can have their meals at separate times or in their room if they wish. This allows individuals to make choices about some aspects of their routines. A four-week rotational menu remains is operation in the home. The service users who were spoken with commented positively on the quality and quantity of the meals provided in the home. Examination of past menus indicated that the home provides wholesome and nutritious meals for the service users thus promoting good health. The inspector had breakfast with service uses on the first floor. Some service users were presenting a challenging behaviour and this contributed the high noisy levels in the dining room. The high needs of some of the service users affected the ambience of the breakfast time. The service of breakfast was served in an organised manner but the state of the cutlery could not be considered as satisfactory. Some of the knives and forks were not clean and in one case the inspector intervened and asked a staff member to provide a service user with cleaner knife and fork. This lack of cleanliness to cutlery is potential risk of contamination of food to the detriment of service users. Suitable arrangements must therefore be made to ensure that cutleries are clean before being issued for use. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18. The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. EVIDENCE: The home has a written complaint procedure, which is regularly reviewed by the company. Summary of the complaint procedure is included in the Service User Guide. There is also a “Whistle Blowing” policy in place and copies of these procedures are also visibly available in the home for visitors to see. Four service users and a visiting relative were spoken with about the complaint procedure and they all indicated that they are aware of the procedure and would know how to complain if they had a need to do so. Examination of the staff training record showed that staff have had training in the protection of vulnerable adults. Three care staff were formally interviewed and they all showed awareness of the home’s complaint and whistle blowing policies. They were able to describe the various forms of elder abuse and indicated how such abuses could be prevented in residential care settings. Such training and awareness amongst staff is one way of reducing the likelihood of abuse to residents. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26. The home is generally clean and warm offering residents a homely environment in which to live. However, there were a number of maintenance issues, which need to be addressed, including the state of the grounds. There is lack of suitable shower facility on the ground floor, thus affecting the health and safety of the service users and the staff, as well compromising the dignity and privacy of the service users who require mechanical assistance to use it. EVIDENCE: The dining facilities could be improved as some tables had ‘wobbly legs’ and some of the older chairs had loose arms. The manager confirmed that the home is expecting delivery of new tables and chairs to replace those that are damaged. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 17 Décor is generally of good standard in the corridors and in bedrooms that have been redecorated recently. However, several of bedrooms need to have new carpets and benefit from redecoration. However, work in this area has already began and some rooms have benefited from re-decoration and renewal of carpets. The home is surrounded by a large grassed area which needs landscaping to create accessible garden space for service users to enjoy. Instead the home is surrounded by overgrown grass. This aspect of the home remains disappointing as it is the first impression given on arrival. The manager confirmed that plans are underway to address this by the company. All the bedrooms are single occupancy. A number of the service users who were spoken with stated that they found their rooms very comfortable and homely. Most have furnished their rooms with personal items thus ensuring homely and familiar environment for them. Service users commented on being happy with having personal belongings in their rooms. It was noticed that the same carpet is used throughout most of the home from the corridors into the bedrooms. The carpet has rough texture and provides no visual cues to the service users that they are entering into their room. The texture of the carpet is rough and may cause injuries to the skin in the event of a service users falling. It was pleasing to note that the carpets in some of the bedrooms are being renewed as a result of previous inspection recommendations. The shower facility on the ground floor is inadequate for the needs of the service users and therefore suitable arrangements must be made within reasonable timescale to address this. The manager and the staff confirmed that most service users on the ground floor prefer the use of the shower. The size of the shower room does not permit more than one carer to assist with showering. Staff described how they were unable to protect the privacy and dignity of those service users who require mobile hoist to assist them to have their shower. The hoist does not fit fully into the shower room and therefore service users are having to be showered with the door open thus compromising their dignity and safety. From the routines described it was evident that the health and safety procedures are seriously being compromised. At the time of the inspection the home was noted to be clean and generally free from offensive odour. However, a number of rooms were identified which require extra cleaning or odour control mechanisms to deal with the bad dour in those rooms. It was noted that all toilets had liquid soap dispensers. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. This also contributes to the health and safety of the service users. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The home maintains adequate staffing levels to meet the needs of the service users. Suitable arrangements for staff training and supervision are in place which ensured that staff provide good quality service that benefits the service users. EVIDENCE: The staffing rotas were examined and found to be sufficient in numbers to meet the care needs of the service users. The manager has some flexibility regarding the deployment of extra staff to meet the needs of the service users. Examination of past rotas showed evidence of staffing levels being consistently maintained. However, because of the high dependency levels of the service users on the first floor it is recommended that the home maintain a minimum of three care staff and a trained on the day shifts. The home maintains a clear policy on recruitment and the manager confirmed that the home follows these policies rigorously. All the staff have been given terms and conditions of employment and job description. The manager confirmed that all staff have had CRB checks done, and evidence of these were made available for inspection. The company has adhered to its employment policies which had led to the right calibre of people being employed leading to low staff turnover resulting in positive outcomes for the service users. Some service users commented that they feel re-assured seeing a well established care team. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 19 The staff training log contained details of the training provided for the staff which included moving and handling, first aid, fire safety training, food hygiene, challenging behaviour management, falls prevention and protection of vulnerable adults awareness training. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, The manager ensures that all staff have guidance and support so that service users needs can be most effectively met. Suitable arrangements for the health and safety, and welfare of service users and staff are in place and are appropriately maintained. EVIDENCE: The manager is a qualified RMN and is support by a deputy who is RGN trained. They both have long experience of working in nursing homes, and have had extensive management experience in care settings. The manager and the deputy work very closely together, complementing each other. This arrangement has enhanced the skills mix within the home to the benefit of the service and the service users. The staff who were spoken with acknowledged that the manager is new in post but has effectively established himself as a credible manager and indicated Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 21 that he runs the service for the benefit of the service users and has positive relations with the staff. Records relating to health and safety and general maintenance were examined. These showed that safety measures relating to fire and environmental health matters were being observed and appropriate records are maintained as evidence. The fire-log book provided evidence of regular fire alarm tests and maintenance of fire detection and fire fighting equipments. Care staff who were spoken with demonstrated good knowledge of the fire procedures in the home. They were able to describe what to do in the event of discovering fire in the home. The staff training record also indicated that all staff have had fire training. There was also record of regular testing of hot water in bedrooms and bathrooms to ensure that the water temperatures remain within the recommended safety range. These arrangements have been maintained to ensure the safety of the residents. The company has produced detailed Health and Safety policies and copies of these were made available for inspection. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The manager stated that staff have had training in food hygiene, fire precaution and first aid. All portable appliances have been tested. A record is maintained of monthly water temperature tests in the home. There is evidence of regular servicing of fire equipment, gas and electrical appliances being carried out by the company. All the servicing records that were examined were up to date. These included fire fighting equipments, servicing of hoists, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 2 3 2 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 3 x 3 Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 15 19 Regulation 13(4)(c ) 16(2)(c ) Timescale for action Suitable arrangements must be 14 made to ensure that cutleries are september kept clean. 2005 The heights of mirrors, toilet roll 15 January holders and soap dispensers in 2006 accessible WC’s need to be relocated to meet the needs of disabled service users.Replace / repair broken dining tables and chairs on both floors. The shower facility on the 30 June ground floor is inadequate for 2006 the needs of the service users and therefore suitable arrangements must be made within reasonable timescale to address this. Suitable arrangements must be 1 made to ensure an effective December odour control in some of 2005 bedrooms. The Registered Provider must 1 make arrangements for the December service user to acknowledge in 2005 writing how the home will manage financial accounts held on their behalf. Requirement 3. 25 23(2)(n) 4. 26 16(2)(j) 5. 35 16(1) Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 25 Good Practice Recommendations The provider should make suitable arrangements to provided a pleasant external surrounding round home. This should include a landscaped garden for use by the service users. Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maple Lodge Nursing Home B52 B02 S18201 Maple Lodge V219798 07 Sep 05 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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